Standard Request - Health Care Providers and Caregivers

Standard Request - Health Care Providers and Caregivers

All fields with an asterisk (*) are mandatory
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Organization*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Which tool(s) are you requesting permission to use?*

Palliative Performance Scale Version 2 (PPSv2)Bereavement Risk Assessment Tool (BRAT)Bowel Performance ScaleRespiratory Congestion ScalePsychosocial Assessment Tool10 Steps to Better Prognostication Table
Please specify what language(s) you would like for the PPSv2:*
What is your role in palliative care?*
Would you be using the tool(s) for profit?*

YesNoNot sure
Please select the purpose for which you're requesting the tool.*

Clinical and educationEMRResearchBookWebsiteTranslationOther
Please provide more information about how you will use the tool(s)*
Please review and check each clause to confirm you agreement with the copyright permission terms:

Permission is granted for non-exclusive rights to publish the tool(s) in the requested language only.A credit line will appear at the bottom of the tool(s) and will include Copyright Victoria Hospice Society, BC, Canada www.victoriahospice.org.No modifications to the content, structure and meaning of the tool(s) is allowed.The tool(s) must be published with complete usage instructions, including the chart, instructions for use and definition of terms.The tool(s) must not be used in any way that generates profit from the tool(s) itself, including resale, licensing, or commercial distribution.
Should be Empty: